Paragraph 27 of the FCC’s Lifeline Modernization NPRM asked for “comment on additional broadband health care related initiatives that can significantly improve the health outcomes for low-income consumers.” Here’s how NDIA responded in our comments:
Lack of broadband access is a major obstacle to low income households’ adoption of Personal Health Record (PHR) tools. We recommend the Commission work cooperatively with the Department of Health and Human Services and the Centers for Medicare and Medicaid Services to maximize the impact of a Lifeline broadband option on low-income PHR adoption.
The lack of home Internet service of any kind in more than half of U.S. households with incomes below $20,000 (as reported by the 2013 American Community Survey among others) stands directly in the way of efforts by hospital systems, community health clinics, and the Centers for Medicare and Medicaid Services (CMS) to promote the use of PHRs by Medicaid and low-income Medicare patients, as an essential element of ensuring “meaningful use” of Federally subsidized Electronic Health Records systems.
PHR applications (sometimes called, more accurately, “patient portals” or “personal health management apps”) are the consumer-facing portions of healthcare providers’ Electronic Health Records systems. Typically available to an enrolled patient through secure login at the provider’s website, a PHR such as Epic Systems’ “MyChart” provides not only access to test results and other record information, but also online appointment scheduling, prescription renewal, patient self-education resources from trustworthy sources, and email communication with doctors and nurses.
To continue to receive enhanced reimbursements from CMS’ Medicaid and/or Medicare EHR Incentive Programs, healthcare providers must enlist large numbers of low-income and/or elderly patients to create and use their PHR accounts. The CMS reimbursement incentives are especially important for safety-net hospital systems and community health clinics, many of which which have added large numbers of Medicaid patients under the Affordable Care Act. Unfortunately, poorer and older residents are exactly the groups least likely to have computers, home Internet access or even reliable smartphones.
Providers have important reasons other than federal reimbursement to encourage their low-income patients to use their PHRs: Less patient time wasted in waiting rooms and call-waiting queues, less staff time and paperwork wasted on routine tasks like prescription renewal, more efficient appointment scheduling, and a convenient system for communicating test results, care reminders, questions and answers. In addition, some providers now use their PHR platforms to conduct patient surveys or support active telehealth applications. These administrative advantages and clinical tools are as valuable for improving care and outcomes for low-income patients as for those who are better-off and better-connected.
Unfortunately, the persistent gap in home broadband access and digital literacy for low-income households mean that: a) significantly lower percentages of Medicaid patients are enrolling as early PHR adopters than are patients with private insurance, and b) in many communities there is a hard ceiling on PHR adoption by low income households, because half or more have no broadband access, fixed or mobile.
We encourage the Commission to:
1) Identify the effective use of current and future Personal Health Record applications, including effective user access to data, documents and media, as one of the benchmarks for establishing its minimum standards for speed, bandwidth and device capabilities that would be supported by any Lifeline Internet subsidy.
2) Invite appropriate officials of the Department of Health and Human Services, including the Centers for Medicare and Medicaid Services, to join with FCC staff and other concerned parties to discuss how these agencies might coordinate efforts to maximize the impact of a Lifeline broadband option on low-income PHR adoption — for example, through support for community marketing and consumer training initiatives.
3) In establishing criteria for approving innovative or non-conventional Lifeline broadband providers, give weight to the proposed provider’s ability and intent to provide training in support of PHR adoption.
(In a footnote, we gave this example of the problem.)
MetroHealth is a large safety-net hospital system serving Cleveland and Cuyahoga County, Ohio. The system saw about 300,000 individual patients between January 2012 and May 2015. 58% were either covered by Medicaid or were uninsured. Only 30% had commercial insurance coverage.
The 2013 American Community Survey showed that Cleveland remains one of the nation’s poorest big cities, and also one of the worst-connected; 41% of the city’s households had incomes below $20,000, and only 37% of those sub-$20,000 households reported having any kind of home Internet subscription (including mobile). Separately, a countywide phone survey commissioned by OneCommunity’s Connect Your Community Project, and carried out in October 2012, found the percentage of fixed home broadband users among Medicaid clients to be only 42% countywide, and just 38% in the city of Cleveland and adjacent lower-income suburbs.
A recent analysis of MetroHealth’s 75,000 MyChart users by researchers from the Center for Health Care Research and Policy found that only about 20% of the system’s Medicaid-covered patients had logged in, compared to 36% of commercially insured patients. They also found, looking at the percentages of users who engaged in “Common PHR Activities” such as reading messages, viewing lab results, checking allergies and requesting advice, that “Medicaid and uninsured patients had noticeably lower levels of use across all categories”. The researchers characterize this pattern as “An Emerging Inequality”, and comment that “Differences in the uptake and use of PHRs could increase or exacerbate health disparities.”
MetroHealth’s Chief Informatics Officer, Dr. David Kaelber, expanded on this concern in a June 10, 2015 letter to the Broadband Opportunity Council: “MetroHealth can already see Cleveland’s economic digital divide reflected in our MyChart user data… There is good reason for concern that this disparity may widen, as continuing efforts to add MyChart users run up against the limited supply of lower-income patients who are actually able to respond.”